Sexual Dysfunctions Paraphilic Disorders and Gender Dysphoria

Sexual and Gender Identity Disorders

• What is “normal” vs. “abnormal” sexual behavior? Need to
consider:
• Normative (i.e., common, average) facts and statistics
• Cultural considerations
• Gender differences in sexual behavior and attitudes

What is Normal Sexuality?

• 15 or more partners (lifetime)
• M = 21.4%
• F = 8.3%
• 4 or more partners (past year)
• M = 6%
• F = 2.9%
• Homosexual sex attraction or
behavior
• Men = 10%
• Women = 9%

Sex in Older Adults

• Activity can and does last past
age 80
• Age 75 to 85
• M = 38.5% active
• F = 16.7% active
• Decrease in sexual activity
attributable to physical health
changes

Gender Differences in Masturbation

• Masturbation
• M = 72% report ever masturbating
• F = 42% report ever masturbating
• Reasons for discrepancy: Male masturbation may be easier,
physical gratification more emphasized for men

Gender Differences in Sexual Frequency

• Casual premarital sex
• Men are more permissive, but gap is shrinking
• Elements of satisfaction
• Women = More likely to seek demonstrations of love, intimacy
• Men = More likely to focus on arousal
• No differences in several domains
• Acceptability of homosexuality
• Acceptability of masturbation
• Importance of sexual satisfaction

Gender Differences in Sexual Beliefs

• Sexual self-schemas: Beliefs about one’s own sexuality
• Females more likely to value experience of passionate and romantic
feelings
• Minority of females hold embarrassed, conservative, or self-
conscious views toward sex
• Males have fewer negative core beliefs about sex; more likely to
emphasize dominance and aggression

Cultural Differences

Views on sexuality in children
• Sambia people (Papua New Guinea)
believe receiving semen contributes
to development in children >
emphasize homosexual oral sex
between teenage and young boys
• Munda (India) emphasize mild
heterosexual activity (e.g., mutual
masturbation) among cohabiting
children
• Permissiveness toward casual sex
varies

The Development of Sexual Orientation

• The development of sexual
orientation
• Interaction of bio-psycho-social
influences
• The example of homosexuality
• Only small genetic component: 50% of
identical twins raised together (i.e., same
genes and environment) do not share the
same sexual orientation

Homosexuality in DSM History: A disorder?

DSM‑III‑R removed homosexuality as a disorder
because:
• No physiological differences in arousal between
homosexuals and heterosexuals.
• No difference in rate of psychological disturbance
• Gender identity confusion no more common in
homosexuals
• Because of a lack of full societal acceptance, and
different behaviors, homosexual sexual concerns may
differ significantly from heterosexuals’ concerns.

Overview of Sexual Dysfunctions

Sexual dysfunctions
• Involve desire, arousal, and/or orgasm
• Pain associated with sex can lead to additional dysfunction
• Must now be present for 6+ months in order to make diagnosis
• Must lead to impairment or distress in order to be considered a
disorder

Prevalence of Sexual Dysfunctions

• Sexual difficulties are extremely common
and not always distressing
• One study: 40% of men had some
difficulty with erection/ejaculation, 63%
of women had problems with
arousal/orgasm
• Males and females experience parallel
versions of most dysfunctions

Classification of Sexual Dysfunctions

• Lifelong vs. acquired
• Generalized vs. situational
• Psychological factors alone
• Psychological factors
combined with medical
condition

Male Hypoactive Sexual Desire Disorder:
An Overview

Little or no interest in any type of sexual activity
• Masturbation, sexual fantasies, and intercourse are rare
• Accounts for half of all complaints at sexuality clinics
• Affects 5% of men in terms of lifetime prevalence

Erectile Disorder

• Difficulty achieving or maintaining an erection
• Sexual desire is usually intact
• Most common problem for which men seek treatment
• Prevalence increases with age
• 60% of men over 60 experience erectile dysfunction

Female Sexual Interest/Arousal Disorder:
An Overview

• Lack of or significantly reduced sexual interest/arousal
• Typically manifesting in:
• reduced sexual interest
• reduced sexual activity
• fewer sexual thoughts
• reduced arousal to sexual cues
• reduced pleasure or sensations during almost all sexual encounters

Female Orgasmic Disorder

• Marked delay, absence, or decreased intensity of orgasm in almost all
sexual encounters
• Not explained by relationship distress or other significant stressors
• 1 in 4 women has significant difficulty achieving orgasm

Premature Ejaculation

• Ejaculation occurring within ~1 minute of penetration and before
it is desired
• Most prevalent sexual dysfunction in adult males
• Affects 21% of all adult males
• Most common in younger, inexperienced males
• Problem tends to decline with age

Genito-Pelvic Pain/Penetration Disorder

• In females, difficulty with vaginal
penetration during intercourse,
associated with one or more of
the following:
• Pain during intercourse or
penetration attempts
• Fear/anxiety about pain during
sexual activity
• Tensing of pelvic floor muscles in
anticipation of sexual activity

Assessing Sexual Behavior: Interviews

• Clinician must demonstrate comfort with topic
• Assess multiple dimensions
• Sexual attitudes
• Behaviors
• Sexual response cycle
• Relationship issues
• Physical health
• Psychological disorders

Assessing Sexual Behavior: Assessment

• Medical evaluation
• Medication side effects
• Physical conditions
• Psychophysiological assessment
• Sexual arousal in response to
erotic material
• Males—Penile strain gauge
(measures erection)
• Females—Vaginal
photoplethysmograph
(measures blood flow to
vagina)

Causes of Sexual Dysfunctions: Biological

• Physical disease
• Chronic illness
• Prescription medications
(e.g., antihypertensive
medication)
• Alcohol and drugs

Causes of Sexual Dysfunction: Psychological

People with sexual dysfunction are more likely to experience anxiety and
negative thoughts about sexual encounters
• May actively avoid awareness of sexual cues
• Example: Men with ED tend to distract themselves purposefully to avoid orgasm

Effect of anxiety on sexual arousal

• Previously believed to decrease arousal and contribute to sexual dysfunction
• But in some cases, anxiety (e.g., about getting an electric shock in the
laboratory) increases arousal in response to erotic material

Causes of Sexual Dysfunctions:
Socio-Cultural

Erotophobia: Associate sexuality with negative feelings, anxiety, or
threat
• Unpleasant or traumatic sexual experiences
• Poor interpersonal relationships
• Lack of communication

Treatment of Sexual Dysfunction: Education

• Education alone can be surprisingly effective
• Masters and Johnson’s psychosocial
intervention
• Education about sexual response, foreplay, etc.
• Sensate focus and nondemand pleasuring
• Sexual activity with the goal of focusing on sensations
without trying to achieve orgasm
• Decreases performance anxiety

Treatment of Sexual Dysfunction:
Psychosocial Procedures

• Additional psychosocial procedures
• Squeeze technique – premature ejaculation
• Masturbatory training – female orgasm disorder
• Use of dilators – vaginismus
• Exposure to erotic material – low sexual desire problems

Medical Treatment of Sexual Dysfunction: Viagra

is it really the wonder drug?
• Headache side effects, many discontinue
• Injection of vasodilating drugs into the penis
• Testosterone
• Penile prosthesis or implants
• Vascular surgery
• Vacuum device therapy
• Few medical procedures exist for female
sexual dysfunction; Levitra is most
commonly used

Nature of paraphilic disorders

misplaced sexual attraction and
arousal
• Focused on inappropriate people or objects
• Often multiple paraphilic patterns of arousal
• High comorbidity with anxiety, mood, and substance use disorders
• Manifest in fantasies, urges, arousal or behaviors
• Paraphilia is not always disordered
• Only considered disordered when the individual
• Experiences clinically significant distress or impairment OR
• Acts on urges with a nonconsenting person

Frotteuristic Disorder

• Persistent pattern of seeking sexual gratification from rubbing
up against unwilling others
• Often occurs in crowds and/or confining situations from which the
other person cannot escape
• Examples: Crowded elevator or subway

Fetishistic Disorder

• Sexual attraction to nonhuman objects
• Objects can be inanimate and/or tactile
• Examples
• May include rubber, hair, feet, objects such as shoes

Voyeurism

• Observing an unsuspecting individual undressing, naked or engaged in
sexual activity
• Risk associated with “peeping” may intensify sexual arousal

Exhibitionism

• Exposure of genitals to unsuspecting strangers
• Element of thrill and risk is necessary for sexual arousal

Transvestic Disorder

• Sexual arousal with the act of cross-dressing
• Males may (rarely) show highly masculine compensatory behaviors
• Most do not show compensatory behaviors
• Many are married and the behavior is known to spouse
• Not inherently pathological; only considered disordered if it causes
significant distress or impairment

Sexual sadism

Inflicting pain or humiliation to attain sexual gratification

Sexual masochism

Suffering pain or humiliation to attain sexual gratification

Sadistic Rape

• Some rapists are sadists, but most are not
• Most rapists do not show paraphilic patterns of arousal
• Rapists tend to show sexual arousal to violent sexual and non-sexual
material

Pedophilic Disorder

sexual attraction to prepubescent children
• Vast majority of sufferers/perpetrators are males
• Pedophilia is rare, but not unheard of, in females
• In some cases, pedophilic urges are limited to incest (i.e., young
members of one’s own family)
• Many sufferers do not act on desires
• Some engage in compensatory moral behavior

Pedophilia associated features

• Incestuous males may be aroused by adult women
• Male pedophiles are usually not aroused by adult women
• Some rationalize the behavior
• E.g., consider pedophilic activity to be an act of affection or a teaching experience
• Often engage in other moral compensatory behavior
• Pedophile profile: passive, impulsive, alcoholic, low social skills,
possible brain dysfunction/TBI
• Most (90%) pedophiles and incest perpetrators are male (Barlow &
Durand, 2004)
• Use of physical force relatively rare, usually other forms of
manipulation are used

Causes of Paraphilic Disorders

• Difficulty forming “normal” relationships
• Deficits in typical sexual experiences
• Relationship difficulties in childhood or adolescence
• Early experiences may lead to sexual associations by chance > then
reinforced through masturbation
• Often have very high sex drive
• Suppressing unwanted fantasies may paradoxically increase them

Psychosocial Interventions for Paraphilic Disorders

• Target deviant and inappropriate sexual associations
• Covert sensitization – imagining aversive consequences to form negative
associations with deviant (e.g., pedophilic) behavior
• Orgasmic reconditioning – masturbation to appropriate (adult) stimuli
• Extinction or aversive conditioning
• Assertiveness training, social skills training
• About 70% to 100% of cases show improvement
• Most pedophilias run a chronic course and relapse rates are high.
• Poorest outcomes are for rapists and persons with multiple paraphilias.

Effectiveness for Psychosocial Treatment
for Paraphilic Disorders

• Efficacy is mixed
• Poorest outcomes = Rapists and patients with multiple
paraphilias
• Incarcerated offenders are difficult to treat
• Chronic course
• High relapse rates
• Outpatient treatment is more successful

Drug Treatments: Cyproterone acetate

“chemical castration”)
• Reduces desire and
fantasy dramatically,
but they return after
drug removal

Drug Treatments: Depo-Provera

reduces testosterone

Most useful for dangerous
sexual offenders; some
take the drug to avoid
going to prison

Gender Dysphoria: An Overview

• Clinical overview
• Feeling trapped in the body of the
wrong sex
• Often assuming identity of the
desired sex
• Causes are unclear
• Gender identity usually begins
between 18 to 36 months of age
• Fluid or cross-gender identity is not a
disorder unless it causes significant
distress or impairment

Gender Dysphoria

• Relatively rare in terms of prevalence
• More common in males-between 5 to 14 per thousand versus 2 to 3
per thousand in females
• Rates are similar across cultures
• Some cultures revere individuals with nontraditional gender
experience (e.g., biological male adopting a female role seen as a
shaman)

Causes of Gender Dysphoria

• No clear biological causes identified, but likely has genetic
component
• Studies have found that 62 to 70% of variance in gender expression
is explained by genetics
• Exposure to certain hormones in the womb (e.g., higher levels of
testosterone may masculinize a female fetus) but evidence is
inconclusive.

Treating Gender Dysphoria:Sex Reassignment Surgery

• Must be psychologically/socially stable and live as desired gender for
several years first
• 75% report satisfaction with new identity
• Female-to-male conversions adjust better

Treating Gender Dysphoria: Treatment of intersexuality

• Often treated with surgery at birth; subsequent gender dysphoria may need
to be addressed

Treatment of Gender Nonconformity in Children

• Gender nonconformity is common and may not
lead to gender dysphoria
• Gender nonconformity can lead to negative social
experiences
• Conflict between affirming child’s identity and
encouraging cis-gender behavior to improve social
adjustment
• Treatment should be individualized to specific
child’s needs and environment

Summary of Sexual and Gender Identity Disorders

• Sexual dysfunctions are vey common
• Problems with desire, arousal, and/or orgasm
• Paraphilic disorders represent inappropriate sexual attraction
• Psychosocial and medical treatment options
• Often efficacious
• Comprehensive assessment and treatment approaches are best
• Gender dysphoria: feeling trapped in body of opposite sex